Pharmacy Benefits

Pharmacy Benefits Manager
Your health insurance benefits include pharmacy benefits. This benefit is included for you and all enrolled dependents when you enroll in health insurance. Pharmacy benefits are administered by Caremark.

Summary of Prescription Drug Benefits
The state's prescription drug plans require a copay. How much you pay depends on how the prescription is filled.

Members pay the lowest amount for a generic (tier one) drug. A generic medicine is FDA approved and equal to the brand name product in safety, effectiveness, quality and performance.

Members pay a higher amount for a preferred brand (tier two) drug. Many popular and highly used preferred brands are included on the drug list.

Members pay the highest amount for a non-preferred brand (tier three) drug. These belong to the most expensive group of drugs. These drugs are not included on the drug list.

Finding a Caremark Network Pharmacy
More than 67,000 independent and chain pharmacies are available throughout this U.S. All offer 30-day prescriptions. If you take a longer term medication, more than 916 Tennessee "mail at retail" pharmacies also fill 90-day prescriptions. Mail service is also available.

You can find a 30-day or 90-day network pharmacy through the Caremark website at info.caremark.com/stateoftn. You can also call Caremark customer service at 877.522.TNRX (8679) to find a network pharmacy near you.

Coordination of Benefits — Other Coverage
Click here to find out how to request reimbursement for prescriptions if you have secondary coverage with the state group insurance program.

Maintenance Drugs
Copays are lower for certain medications from the special, less costly 90-day network. As an incentive to use pharmacies that cost the plan less, there are lower copays on a large group of maintenance drugs. This applies to certain drugs used to treat high blood pressure or cholesterol. View the maintenance drug list, visit caremark.com or call Caremark to determine if your medication is on the list.

Appeals
Members have the right to appeal a denial made by Caremark. There are three levels of appeal available:

First Level Appeal — if the member's prescription requires prior authorization, and the request is denied because it does not meet their plan's approved criteria for use of the medication, the member may choose to appeal the denial. The member or their authorized representative may request that Caremark re-review the request along with any additional clinical information that the member's physician provides. If this appeal request is not approved the member will receive a letter explaining the decision and providing information about how to request a second level internal appeal from Caremark.

Second Level Appeal — if the member's first level appeal is denied, the member or their authorized representative may choose to request that Caremark review the case and make a determination as to whether the drug is medically necessary for the member's treatment. Caremark will review the case and any additional clinical information provided by the member's physician to make this determination. If this appeal is not approved, the member will receive a letter explaining the decision and providing information about how to request an external review of their case from an independent review organization (IRO).

External Review — if the member's second level internal appeal is denied, the member or their authorized representative may choose to request that an IRO review the case and make a final determination. The IRO will communicate their decision to the member. This decision will be final and binding on the member, the plan and Caremark.